April 22, 2014 Leave a comment
A great, straightforward guide to systems from “Find What Works” (by Dave Algoso), that explains pretty well the different layers of thinking about systems. I summarize his post below about healthcare, but in the titles one could easily substitute just about any other field and add its own description. He distinguishes four levels of complexity, and refers to “zooming out” from Level 1 at the center to Level 4:
- Level 1 – “Thinking about healthcare”: Focused on the patient, and the doctor-patient interaction that offers prevention or treatment.
- Level 2 – “Thinking about healthcare systems”: Focused on all of the distinct elements that make that doctor-patient interaction possible (he cites: policy & governance; financing; physical facilities; patient access; workforce development; supply chains; health information systems)
- Level 3 – “Systems thinking about healthcare systems”: Systems thinking adds complexity by considering not just the impact of each element on patient care, but also on all the other elements of the system. (eg: effects of policy on supply chains or workforce development; effects of healthcare information on policy; effects of financing on access or facilities or supply chains…)
- Level 4 – “Systems thinking about healthcare”: At this level, Algoso says, we zoom out beyond the health care system and consider everything that affects health – environment, working conditions, water & sanitation, conflict & stability, food security, etc etc…
At each level, things get more and more complex, and interventions to improve healthcare will depend on what level of analysis we are using. I find this stuff fascinating, especially when it’s presented in such a clear, concise way. Next, I do a little thought exercise on using this analysis in a different context.
So now I take a stab… [post #2]
Currently, my work focuses mostly on child protection in development programs. Just as a thought exercise, I’m using this as a basic framework and seeing how I would analyze child protection programs with this thought process. By “protection”, I am referring to Convention on the Rights of the Child Article 19, meant to ensure children are protected from all forms of violence, abuse, neglect and exploitation.
Level 1 – Thinking about protection:
Already, protection gets a bit more complicated. With healthcare, the clear center is interaction between health professional (doctor, nurse, CHW, birth assistant…) and the patient. However, with a child’s right to protection, the frontline duty-bearers can be a wide range of people. Parents, adults, teachers, health professionals, counselors and psycho-social professionals, case workers… all can have direct responsibility for ensuring a child’s right to protection in various situations. However, boiling it down to its essence, it is ultimately the responsibility of the child’s primary caregiver. So we’ll call this level the “child-caregiver interaction”.
The caregiver, like the doctor, is charged with protecting the child from myriad threats, both mitigating the risk and responding to threats and violations. At every stage of life, the primary caregiver must ensure that a child is safe from those forces that would harm her or him – from the smooth-talking agent who would traffic her to a brothel; from the powerful local businessman who would place him in working conditions too dangerous for his age; from the neighbor who would rape her. Indeed, within the family there may be risks: early marriage, beating, psychological abuse.
There is, however, a second sub-level here: protection by adults other than the primary caregiver. When the child is at school, teachers are responsible; when the child has lost their parents, the State is responsible for ensuring the child gets placed in a protective environment.
What types of interventions would fall under this level? Many NGOs act at this level, filling the caregiver role when the primary caregiver has neglected it, or educating parents and children about their rights. An NGO working to stop child marriages and convince parents to send girls to school instead would be working on child protection at Level 1.
Level 2 – Thinking about protection systems:
Zooming out to the “child protection system”, we now see all the many distinct elements of the system that contribute to – or detract from – child protection. These elements include (borrowing a bit from Algoso): laws & policies; traditional norms and customs about acceptable behavior; enforcement & punishment mechanisms, both formal and informal; children and caregivers’ knowledge of threats – both of the potential negative impacts and the likelihood of a rights violation in certain situations; physical infrastructure: care centers, protected homes, gender-separated public latrines; protection workforce, professionals and para-professionals, including case workers, law enforcement and legal personnel, psycho-social counselors; reporting mechanisms; information systems; financing of child protection initiatives.
Interventions here would include improving the legal framework or organizational policies; training response personnel (including law enforcement, legal personnel, health workers and counselors, case workers, local leaders, etc); working to change local attitudes about acceptable behavior towards children; building infrastructure better suited to protection (eg separated latrines); improving reporting systems, particularly by using technology that also improves information systems; or building capacity at the national level (eg through policymakers’ motivation, organizational structures, or revenue streams) to fund child protection systems.
I would put it at this level if it addressed only one or a few elements at a time. Hopefully, many of these are done at the same time; even better, they could be part of a coordinated response with each intervention considering how it may spark changes in other elements, which gets us to…
Level 3 – Systems thinking about protection systems:
Following Algoso’s guide, the next level out helps us see the interactions between all these distinct elements of the child protection system. In short, every lever we pull at one element will have ripple effects on all the others; applying systems thinking means trying to identify these effects and plan for them in a comprehensive response. And none of these are static or consistent effects, but they are constantly shifting. Yeah, it’s a bitch.
Maybe we’ve pushed through a better government policy on supporting children affected by AIDS, and made all the legislators feel good. But now they’ve moved on to the next issue without properly funding the implementation. Without that funding, our community case workers are underpaid and feel unsupported in their (emotionally taxing) work, and the professional workforce doesn’t have the resources to implement the new workforce development and promotion policy we helped them design. And maybe our community awareness campaign has, despite being participatory, offended traditional leaders since in their eyes it implied that they have a problem with this controversial subject. Now the community case workers – and the orphans and vulnerable children they’re supposed to protect – are more isolated in their own communities and not receiving necessary support from the government.
Systems interventions should be aware of what those ripple effects are likely to be, and focus on points of high leverage in the system. In particular, they should be attuned to possible differential effects and the potential for exclusion of certain groups (or opportunities for inclusion!). A change in the formal or informal rules may have different impacts on girls, on disabled children, on HIV-positive parents or children, or on different ethnic or religious groups.
In the sample intervention above, maybe the crucial delay in the system that we didn’t address was that group of traditional leaders or local opinion leaders, who can influence others to adopt a more caring attitude towards those children, smoothing the way for formal services and potentially even increasing local demand for services. Of course, we might also have to tailor our outreach to leaders of different religions or ethnic groups, and this tailoring should be developed with real input from local leaders, inclusion or gender experts, and representatives from marginalized groups to make sure nobody is left out.
Level 4 – Systems thinking about protection:
This level zooms out beyond the child protection system to look at all the larger environmental elements that impact protection. Here, the child-caregiver interaction is still in the center, but This would include, of course…
Emergency situation: Clearly, any violent conflict or natural disaster expose children to direct threats, as well as indirect threats to the ability of parents, civil society, or governments to protect children from violence, exploitation, abuse and neglect.
Economic situation: Family poverty can have direct and indirect impacts on a child’s vulnerability to protection risks (again, differential impacts for boys and girls). In addition, the overall economic situation of a country affect those risks as well. For example, certain industries are prone to child labor in unregulated environments, such as gold mining, cocoa farming, shoe or garment manufacturing, and sex tourism – note both licit and illicit. (Of course there are many others.)
Social, cultural, or religious situation: Often, broader social or religious norms can raise different vulnerabilities for children to protection risks. For example, in Senegal, the high value placed on Koranic education leads some children to be exploited as street beggars. In other situations, families that are socially isolated have fewer assets available to ensure child protection (eg HIV-positive parents or those who have been culturally shamed), as support of relatives or communities can often be crucial to a family’s ability to reduce vulnerability of their children.
Political situation: Political issues can have any number of unpredictable effects on child protection, whether it’s distracting attention, diverting resources, or actively creating a hostile environment. And not just the political situation in a given country, but also the global situation – eg, gag rules imposed by certain US administrations can prevent projects from talking about ways for girls to protect themselves from pregnancy or STDs; or sanctions imposed by global powers can limit a country’s ability to fund child protection initiatives.
Migration: Often linked, of course, to emergencies or economics, migration and urbanization can increase vulnerability by removing children and families from familiar people, norms, and situations – and by putting them under the radar of formal systems.
Technology: Mobile technology and the internet can expose children to risks but also allow innovative ways to address problems.
Even in these limited descriptions, I couldn’t avoid overlaps between these different elements. And of course, a lot of them (eg sanctions, negotiations to end conflicts, demand for cheap gold or shoes) may be too big for most NGOs to deal directly with. But interventions can still address key leverage points or delays in these larger systems that impact child protection issues. Algoso cites the adage, “an ounce of prevention is worth a pound of cure” to suggest that NGOs can be effective by anticipating and addressing broader issues, and the ripple effects can help address protection issues as well. However, I think it’s unwise to rely on this sort of strategy without also monitoring those ripple effects and continuing to strategically intervene at other “zoomed-in” levels.
Still, with the obligatory no-silver-bullets disclaimer, this is a great framework for analyzing protection issues and designing responses.